Estamos comprometidos con brindar terapia farmacológica apropiada, de alta calidad y rentable a todos los miembros de Ambetter Health. Use nuestra Lista de medicamentos preferidos para encontrar más información sobre los medicamentos que Ambetter Health cubre.

• Formulario/Lista de medicamentos recetados para 2025 (PDF)
  
• 2025 Formulary Changes (PDF)
• Formulario/Lista de medicamentos recetados para 2024 (PDF)
  
• CGM (Continuous Glucose Monitors) - FreeStyle Libre (Preferred)
• Suministros de recetas por un período extendido de 90 días (PDF)

 PA Formularios

• CoverMyMeds
• Formulario de solicitud de autorización previa para medicamentos no especializados - Retail Pharmacy (PDF)
• Medical Benefit - Buy And Bill Request (PDF)

Evolent - Oncology

All oncology-related chemotherapeutic drugs and supportive agents will require prior authorization from Evolent before being administered in a physician’s office, outpatient hospital, or ambulatory setting. This process applies to both Medical Benefit (Buy and Bill Request) AND Pharmacy Services (Retail Pharmacy)

Pre-Approval Process

The requesting physician must complete an authorization request using one of the following methods:

• Log in to the Evolent Provider Web Portal.
• Call 1-888-999-7713 and select option 1, from 8 a.m. to 8 p.m. EST, Monday through Friday. General Evolent  Information.
• Evolent FAQ (PDF)